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Cholesteatoma

​Cholesteatoma is a unique disease of your ear in which a skin cyst grows into the middle ear and mastoid. The cyst is not cancerous but can erode tissue and cause destruction of your ear.​

How does cholesteatoma form?

There are several theories on how a cholesteatoma forms. Most evidence indicates that improper function of your Eustachian tube contributes to the formation of a cholesteatoma.

If the Eustachian tube does not open often enough to equalize the pressures in the middle ear, negative pressure will develop behind the ear drum. This causes the drum to become retracted, forming a pocket.

As the pocket deepens, it becomes trapped in your ear as a skin cyst or sac. Like skin tissue anywhere in the body, dead skin cells slough off. This also occurs in the cholesteatoma sac.

As more dead skin cells slough off, the sac gradually expands and a cholesteatoma develops. In other cases, skin grows around the margin of a perforation onto the middle ear.

How is cholesteatoma related to ear infections?

If you have had previous problems with middle ear fluid and/or infections, you may be more likely to develop a cholesteatoma. However, it may be years before the cholesteatoma forms. Please understand that most patients with a history of ear fluid / infections do not develop a cholesteatoma.

Can the cholesteatoma sac become infected?

Ear infections are common with cholesteatoma and can lead to a foul smelling discharge that may contain blood. Antibiotics, either systemic (by mouth) or as ear drops, can help control the infection, but will not cure the patient of the cholesteatoma.

How does the patient know if they have cholesteatoma?

Most of the time, patients do not know a cholesteatoma is present. The expanding cholesteatoma sac generally causes destruction of the ear drum and ossicles (bones of hearing). This causes hearing loss. There can be discharge from the ear. It is usually intermittent (comes and goes), but can be persistent. Sometimes this discharge is bloody. Cholesteatoma is not often painful. However, infection may occasionally​ occur, causing pain and swelling behind the ear. A cholesteatoma is detected only by examining the ear and finding the disease. However, the physician may suspect the disease when some or all of the following are present:

Gradual loss of hearing

Discharge from the ear

History of past ear infection / fluid problems

Will antibiotics or ear drops clear up cholesteatoma?

In almost all cases, surgery is necessary to remove the disease. Occasionally, enough of the cholesteatoma debris can be removed in the office with periodic cleaning of the ear to control the disease. However, this approach is generally used in patients who cannot undergo cholesteatoma surgery.

What if cholesteatoma surgery is not performed?

The cholesteatoma will usually grow or expand if not removed. With this growth, there is further destruction of the ear structures. The patient is at risk for further infections, which in some cases, can be quite severe (such as mastoiditis or meningitis.) However, it is generally not necessary to remove cholesteatomas on an urgent basis.

How is cholesteatoma surgery performed?

To have an understanding of cholesteatoma surgery, some terms should be defined:

Tympanoplasty​​: Surgery that involves the tympanum (middle ear). The tympanum is the area of the ear behind the ear drum where the bones of hearing (ossicles) are located.

Mastoidectomy: Surgery performed in the mastoid, where disease may occur.

Tympanomastoidectomy: A surgical procedure that involves both the tympanum and mastoid.

Ossiculoplasty: (ossicular reconstruction): Repair or reconstruction of the ossicles (bones of hearing). There are many techniques and many types of prostheses that can be used for the reconstruction.

There are two basic surgical approaches to the ear:

Transcanal: Performed through the ear canal.

Postauricular: Performed by making an incision behind the ear and moving the ear forward to allow exposure of the mastoid and middle ear.

In some cases, these approaches are combined to obtain the best exposure.

The approach used depends partly upon the location and size of the cholesteatoma and partly upon the preference and experience of the surgeon. There are a number of factors that are taken into account when the surgeon decides what procedure is best. These factors include:

The extent of the cholesteatoma

The size of the mastoid

The primary goal of cholesteatoma surgery is to remove the disease; the secondary goal is to restore or maintain hearing.

Are there risks with this surgery?

Any surgical procedure carries potential risks. These risks need to be discussed with the patient and/or family prior to surgery.

Hearing loss: There is a slight chance of hearing loss in the inner ear. This loss can be complete and permanent.

Dizziness: Some people experience dizziness that resolves within a day of surgery. It is not likely for dizziness to be a persistent problem.

Facial paralysis: The nerve that innervates the muscles of the face courses through the ear. Therefore, there is a slight chance of a facial paralysis. This facial paralysis affects the movement of the facial muscles for closing of the eye, making a smile and raising the forehead. The paralysis could be partial or complete. It may occur immediately after surgery or have a delayed onset. Recovery can be complete or partial.

Tinnitus (noises in the ear): Tinnitus can occur with surgery, but is an uncommon postoperative problem.

Taste abnormalities: A small nerve that innervates some of the taste and salivary function courses through the ear . After ear surgery, some people experience an abnormal taste in the mouth or some dryness of the mouth. Many times this problem will improve over time.

It is generally felt that the occurrence of these potential complications is less with surgeons who are well trained in otologic surgery, have experience in performing these surgeries and perform these procedures on a regular basis. Along with these otologic risks, any surgery carries the risk of anesthesia, bleeding, infection and other more remote operative problems.

Do patients receive anesthesia for cholesteatoma surgery?​​​

Most cholesteatoma surgeries are performed under general anesthesia. Some can be performed with intravenous sedation and local anesthesia. Few are performed with local anesthesia only.

For more information on cholesteatoma you can request a video from Marshfield Clinic Ear Nose and Throat.